title: National outbreak of Salmonella serotype saintpaul infections: importance of Texas restaurant investigations in implicating jalapeño peppers.
abstract: BACKGROUND
  In May 2008, PulseNet detected a multistate outbreak of Salmonella enterica serotype Saintpaul infections. Initial investigations identified an epidemiologic association between illness and consumption of raw tomatoes, yet cases continued. In mid-June, we investigated two clusters of outbreak strain infections in Texas among patrons of Restaurant A and two establishments of Restaurant Chain B to determine the outbreak's source.
  
  
  RESULTS
  We conducted independent case-control studies of Restaurant A and B patrons. Patients were matched to well controls by meal date. We conducted restaurant environmental investigations and traced the origin of implicated products. Forty-seven case-patients and 40 controls were enrolled in the Restaurant A study. Thirty case-patients and 31 controls were enrolled in the Restaurant Chain B study. In both studies, illness was independently associated with only one menu item, fresh salsa (Restaurant A: matched odds ratio [mOR], 37; 95% confidence interval [CI], 7.2-386; Restaurant B: mOR, 13; 95% CI 1.3-infinity). The only ingredient in common between the two salsas was raw jalapeño peppers. Cultures of jalapeño peppers collected from an importer that supplied Restaurant Chain B and serrano peppers and irrigation water from a Mexican farm that supplied that importer with jalapeño and serrano peppers grew the outbreak strain.
  
  
  CONCLUSIONS
  Jalapeño peppers, contaminated before arrival at the restaurants and served in uncooked fresh salsas, were the source of these infections. Our investigations, critical in understanding the broader multistate outbreak, exemplify an effective approach to investigating large foodborne outbreaks. Additional measures are needed to reduce produce contamination.
authors.affiliation: Scientific Education and Professional Development Program Office, Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. rmody@cdc.gov
authors.forename: Rajal K
authors.initials: RK
authors.lastname: Mody
authors.forename: Sharon A
authors.initials: SA
authors.lastname: Greene
authors.forename: Linda
authors.initials: L
authors.lastname: Gaul
authors.forename: Adrianne
authors.initials: A
authors.lastname: Sever
authors.forename: Sarah
authors.initials: S
authors.lastname: Pichette
authors.forename: Ingrid
authors.initials: I
authors.lastname: Zambrana
authors.forename: Thi
authors.initials: T
authors.lastname: Dang
authors.forename: Angie
authors.initials: A
authors.lastname: Gass
authors.forename: René
authors.initials: R
authors.lastname: Wood
authors.forename: Karen
authors.initials: K
authors.lastname: Herman
authors.forename: Laura B
authors.initials: LB
authors.lastname: Cantwell
authors.forename: Gerhard
authors.initials: G
authors.lastname: Falkenhorst
authors.forename: Kathleen
authors.initials: K
authors.lastname: Wannemuehler
authors.forename: Robert M
authors.initials: RM
authors.lastname: Hoekstra
authors.forename: Isaac
authors.initials: I
authors.lastname: McCullum
authors.forename: Amy
authors.initials: A
authors.lastname: Cone
authors.forename: Lou
authors.initials: L
authors.lastname: Franklin
authors.forename: Jana
authors.initials: J
authors.lastname: Austin
authors.forename: Kristin
authors.initials: K
authors.lastname: Delea
authors.forename: Casey Barton
authors.initials: CB
authors.lastname: Behravesh
authors.forename: Samir V
authors.initials: SV
authors.lastname: Sodha
authors.forename: J Christopher
authors.initials: JC
authors.lastname: Yee
authors.forename: Brian
authors.initials: B
authors.lastname: Emanuel
authors.forename: Sufian F
authors.initials: SF
authors.lastname: Al-Khaldi
authors.forename: Val
authors.initials: V
authors.lastname: Jefferson
authors.forename: Ian T
authors.initials: IT
authors.lastname: Williams
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Griffin
authors.forename: David L
authors.initials: DL
authors.lastname: Swerdlow
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002212:Capsicum / Q000382:microbiology*; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058028:Research Report; D012147:Restaurants / Q000706:statistics & numerical data; D012478:Salmonella Food Poisoning / Q000453:epidemiology; D012480:Salmonella Infections / Q000175:diagnosis / Q000453:epidemiology*; D019779:Salmonella enterica / Q000145:classification; D012703:Serotyping; D013781:Texas / Q000453:epidemiology; D055815:Young Adult